Real-time three-dimensional transesophageal echocardiography (RT-3D-TEE) represents a unique perioperative cardiovascular imaging tool which, without any need for off-line reconstruction, has been shown to be highly valuable for evaluating mitral valve and other intracardiac structures. It is highly probable that, in the near future, RT-3D-TEE will have a positive effect on the perioperative assessment of complex 3D mitral valve structures, as it provides important approaches to the pathophysiology of various mitral valve diseases, including prosthetic valves, and will become incorporated into everyday perioperative practice. The clinical applications and therapeutic implications of perioperative RT-3D-TEE in the thorough assessment of the mitral valve are briefly summarized in this review.